OAR 411-070-0045
Facility Payments

(1)

PRIOR AUTHORIZATION. The Department may reimburse a nursing facility for services provided to a Department resident only if prior authorized after the Department has participated in development of the placement plan and is satisfied that the placement is justified and most suitable for the person according to the Department care plan. The Department may not reimburse a nursing facility for services rendered prior to the date of referral to the Department. A nursing facility must verify that the local SPD/Type B AAA where the facility is located is involved in the placement.

(2)

The facility must confirm an individual’s financial eligibility for Medicaid payment of any nursing facility service with the local office. Medicaid eligibility is based on the requirements outlined in OAR chapter 461. The facility is responsible for collecting resident liability from the resident or their responsible party.

(3)

PAYMENT TO PROVIDER. Provider payments will be made following the month of service. For billing, the Department will mail Form SDS 483, Invoice and Payment Authorization, to each facility.

(4)

RESIDENT’S INCOME. A resident’s income, exclusive of the authorized allowance for personal incidental needs and other prior authorized special needs, will be offset as a credit against the established Department rate paid to that facility.

(5)

REDUCED PAYMENT FOR ABUSE.

(a)

If abuse of a resident, according to the provisions of ORS 441.630 (Definitions for ORS 441.630 to 441.680) to 441.685 (Monitors), is substantiated by the Department, the Department may reduce the payment for the resident(s) for the month the abuse occurred, and until such time as the Department determines the conditions leading to the abuse have been corrected.

(A)

The facility will receive payment for services provided for the resident as determined by the Department. This determination will be based on the absence of appropriate services that resulted in the substantiated abuse of a resident.

(B)

The reduced payment may not be considered a reduction in benefits for the resident.

(b)

The Department will notify the facility by certified mail at least 15 days prior to taking action to reduce payment.

(A)

The notice will include the basis of the Department decision, the effective date of the reduced payment, the amount of the reduced payment, and will advise the facility of their right to request review by the Assistant Director if such request is made in writing within 30 days of the receipt of the notice.

(B)

If a request for review is made, the Assistant Director will include the basis of the Department decision, the effective date of the reduced review and all material relating to the allegation of resident abuse and to the reduction in payment. The Assistant Director will include the basis of the Department decision, the effective date of the reduced determination, based upon review of the material, whether or not to sustain the decision to reduce payments to the facility and will notify the facility of the decision within 20 days of receiving the request for review.

(C)

If the Assistant Director determines not to sustain the decision to reduce payments, the reduction will be lifted immediately. Otherwise, the reduction in payment will remain in effect until the Department determines the conditions leading to the abuse have been corrected.

(D)

If the decision to reduce payment is sustained, the payment reduction will not be recovered in the year end settlement.
[ED. NOTE: Forms referenced are available from the agency.]

Source: Rule 411-070-0045 — Facility Payments, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=411-070-0045.

411–070–0000
Purpose 411–070–0005
Definitions 411–070–0010
Conditions for Payment 411–070–0015
Denial, Termination or Non-Renewal of Provider Agreement 411–070–0020
On-Site Reviews 411–070–0025
Basic Flat Rate Payment (Basic Rate) 411–070–0027
Complex Medical Add-On Payment 411–070–0028
Bariatric Authorization and Payment 411–070–0029
Pediatric Rate 411–070–0033
Post Hospital Extended Care Benefit 411–070–0035
Complex Medical Add-On Effective Start and End Dates and Administrative Review 411–070–0040
Screening, Assessment, and Resident Review 411–070–0043
Pre-Admission Screening and Resident Review (PASRR) 411–070–0045
Facility Payments 411–070–0050
Days Chargeable 411–070–0075
Rates - Facilities in Oregon 411–070–0080
Out-of-State Rates 411–070–0085
Bundled Rate 411–070–0087
Bariatric Criteria and Services 411–070–0091
Complex Medical Add-On Services 411–070–0092
Ventilator Assisted Program - Medicaid Payment 411–070–0095
Resident Funds 411–070–0100
Audit of Personal Incidental Funds 411–070–0105
Resident Property Records 411–070–0110
Temporary Absence from Facility (Bedhold) 411–070–0115
Transfer of Residents 411–070–0120
Discharge of Residents 411–070–0125
Medicare, (Title XVIII) 411–070–0130
Medicaid Payment in Hospitals 411–070–0140
Hospice Services 411–070–0300
Filing of Financial Statement 411–070–0302
Filing of Revised Financial Statements 411–070–0305
Accounting and Record Keeping 411–070–0310
Auditing 411–070–0315
Maximum Allowable Compensation of Administrator 411–070–0320
Consultants 411–070–0330
Owner Compensation 411–070–0335
Related Party Transactions 411–070–0340
Chain Operations 411–070–0345
Allocation of Home Office and Regional Office Costs 411–070–0350
Management Fees 411–070–0359
Allowable Costs 411–070–0365
Capital Assets 411–070–0370
Depreciable Assets 411–070–0375
Depreciation Basis 411–070–0385
Depreciation Lives 411–070–0400
Equity 411–070–0415
Offset Income 411–070–0417
Treatment of Complex Medical Add-Ons 411–070–0420
Base Year Cost Finding 411–070–0425
Resident Days 411–070–0430
Allocation Methods 411–070–0435
Appeals 411–070–0437
Quality and Efficiency Incentive Program 411–070–0439
COVID-19 Emergency Response Incentive Program 411–070–0442
Calculation of the Basic Rate, Complex Medical Rate, Bariatric Rate and Ventilator Assisted Program Rate 411–070–0452
Pediatric Nursing Facilities 411–070–0464
Final Report 411–070–0465
Uniform Chart of Accounts 411–070–0470
Nursing Assistant Training and Competency Evaluation Programs Request for Reimbursement
Last Updated

Jun. 8, 2021

Rule 411-070-0045’s source at or​.us